Print this page Email this page
Users Online: 391
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
REVIEW ARTICLE
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 65-73

Microvascular anastomosis in oral and maxillofacial surgery


1 Department of Oral and Maxillofacial Surgery, IDST, Modinagar, Uttar Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Teerthankar Dental College, Moradabad, Uttar Pradesh, India

Date of Web Publication30-Nov-2016

Correspondence Address:
Farhana Girkar
Building No. 1, B/109, Humera Park, Pathanwadi, Malad (East), Mumbai - 400 097
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.194980

Rights and Permissions
  Abstract 

In maxillofacial surgery, head and neck reconstruction of surgical defects caused by oral cancer is considered a challenging problem. Till recently, most oral and pharyngeal defects were closed primarily using skin flaps or tubed-pedicle flaps of skin from the trunk such as forehead flap, deltopectoral flap, pectoralis major myocutaneous flap; however, these were associated with compromised aesthetic and functional results. The advent of microvascular free tissue transfer over the past two decades has helped us overcome these disadvantages and has enabled the ablative surgeon to undertake surgical procedures that could not have been attempted in the past. Innovations in the field of microsurgery have resulted in better techniques, microscopes, and microinstruments, which have made free flap harvesting much easier. This article will review the various techniques of microvascular anastomosis used in head and neck reconstruction and analyze the newer techniques and methods employed today. It also attempts to provide a brief gist of the various free flaps used in head and neck reconstruction and the ones most expedient in the surgeons' arsenal.

Keywords: Microvascular anastomosis, microvascular free flaps, oral and maxillofacial surgery, reconstructive microsurgery


How to cite this article:
Girkar F, Mittal G, Kalra P. Microvascular anastomosis in oral and maxillofacial surgery. Arch Int Surg 2016;6:65-73

How to cite this URL:
Girkar F, Mittal G, Kalra P. Microvascular anastomosis in oral and maxillofacial surgery. Arch Int Surg [serial online] 2016 [cited 2021 Mar 6];6:65-73. Available from: https://www.archintsurg.org/text.asp?2016/6/2/65/194980


  Introduction Top


The major contribution to head and neck reconstruction over the past two decades has been microvascular free tissue transfer.[1] Free tissue transfers are usually located at the top of the reconstructive ladder and are considered when local or regional tissues are insufficient or suboptimal for reconstruction.[2] A region of donor tissue is selected and isolated on a feeding artery and vein, which is then transferred to the region on the patient that requires reconstruction.[3] The vessels that supply the free flap are anastomosed with microsurgery to matching vessels (artery and vein) in the reconstructive site.

The advances in the techniques and technology that popularized microsurgery began in the early 1960s. The first microvascular surgery, using a microscope to aid in the repair of blood vessels, was described by the vascular surgeon Jules Jacobson in 1960. Contemporary reconstructive microsurgery was introduced by an American plastic surgeon Dr. Harry J. Buncke in 1964. Although primarily developed and used by plastic surgeons, microsurgical techniques are now used by a number of surgical specialities.

This article will evaluate the most commonly used microvascular anastomotic techniques in oral and maxillofacial reconstruction with a brief emphasis on various flaps used for microvascular free tissue transfer.


  Selection of Recipient Vessels in Microvascular Anastomosis Top


Free tissue transfer requires a thorough understanding of the relevant donor and recipient site anatomy of the main arterial and venous supply, major vessel variations, important associated structures, and the associated nerve supply.[2]

The choice of recipient vessels depends upon many factors including vessel diameter, pedicle length, pedicle geometry, presence of atherosclerotic plaques, and evidence of traumatic dissection.[4]

Recipient arteries

The most common recipient neck artery for microvascular free tissue transfer is the facial artery. This branch of the external carotid artery is commonly transected during neck dissection because it traverses the inferior border of the mandible or because it enters the submandibular triangle. Another commonly utilized branch of the external carotid is the superior thyroid artery. The transverse cervical artery from the thyrocervical trunk is another artery which can be used.

Recipient veins

Recipient veins in the neck include the internal and external jugular veins, a stump of the facial or common facial veins, and the transverse cervical vein. Anastomosis to the external jugular (EJ) vein has shown a significantly higher failure rate than that to the internal jugular (IJ) system.[5] Chalian et al.[6] compared the EJ vein and the IJ system and found that venous thrombosis occurred only in the anastomoses to the EJ vein. When no recipient veins are available in the neck, the cephalic vein can be mobilized from the upper arm, as described by Urken.[7]


  Technique of Microvascular Anastomosis Top


The operative field is approximately at level with the surgeons' elbows.[2] The recipient site is positioned for optimal exposure. The orientation of the flap pedicle is checked to ensure that the anastomosis will not be under excessive tension. The vessels to be anastomosed are positioned to allow tension-free, surface-to-surface apposition. The pedicle length and the orientation of the donor and recipient vessels are decided and low-pressure microvascular clamps are applied for vascular control [Figure 1].
Figure 1: Use of double approximating microvascular clamps

Click here to view


Both sets of recipient vessels are checked for open branches near the anastomosis that need to be ligated. The cut edges of the vessels are checked for a clean, uniform edge and re-trimmed, if necessary, to avoid stray tissue ends encroaching into the lumen because these can be foci for thrombosis formation.

Once a satisfactory vessel segment is attained, adventitial cleaning is carried out with sharp curved microsurgical scissors [Figure 2].
Figure 2: Donor and recipient vessel preparation: Trimming of the adventitia

Click here to view


After adequate preparation, the vessels are aligned for suture placement. Fine, non-absorbable sutures appropriate to the size and thickness of the vessels are used (most commonly 8-0, 9-0, or 10-0 nylon). These sutures should be placed an equal distance apart to distribute the tension evenly around the circumference of the anastomosis [Figure 3] and [Figure 4]. Arterial anastomoses are usually performed with interrupted sutures and venous anastomoses with continuous sutures.
Figure 3: Suturing the vessel ends

Click here to view
Figure 4: Suturing the vessel ends

Click here to view



  Types of Anastomosis Top


End-to-end anastomosis

The end-to-end anastomosis (EEA) is the simplest anastomosis concept, i.e. the sharply cut end of the donor vessel is sutured to the cut end of the recipient vessel.[4] Alexis Carrel,[8] originally described EEA for microvascular anastomosis, which involves placing two sutures 120–150° apart, followed by a third suture in a position to complete an isosceles triangle [Figure 5]. Additional sutures are then placed between the initial three sutures until the anastomosis is complete.
Figure 5: The "Carrel Method" for end-to-end vessel anastomosis

Click here to view


An alternative technique more commonly used today is the halfway estimation technique [Figure 6].[4] In this, the first two sutures are placed at approximately 180° or more from each other. The third suture is placed at a point halfway between the first two followed by the placement of the remaining sutures. Continuous running sutures can also be used for anastomosis [Figure 7].
Figure 6: The halfway estimation technique for end-to-end vascular anastomosis

Click here to view
Figure 7: End-to-end anastomosis using running sutures

Click here to view


End-to-side anastomosis

The end-to-side (ESA) is applied in situations where properly sized recipient vessels are unavailable, or the flow pattern of the selected recipient vessel must be maintained rather than sacrificing it for the sole purpose of supplying the flap. The most common ESA performed clinically in head and neck reconstruction is for venous outflow of a donor vein to the IJ vein.

To create the ESA [Figure 8], a venotomy appropriate to the size of the lumen of the donor vessel is created slightly larger than the cut end of the donor vessel in an elliptical or diamond shape. Two ends of the venotomy are sutured to the donor vessel [Figure 9]. The remaining sutures are then placed in a running fashion starting with the back wall [Figure 10] and [Figure 11]. When complete, the end is tied to the tail of the opposite “anchoring” suture. The same suturing technique is then performed on the front wall to complete the anastomosis. Alternatively, an interrupted suture technique may be performed on both walls [Figure 12].
Figure 8: Use of vessel loops during end-to-side venous anastomosis

Click here to view
Figure 9: Initial suture placement in end-to-side anastomosis

Click here to view
Figure 10: “Back-wall” sutures placed first from inside the lumen for end-to-side anastomosis

Click here to view
Figure 11: End-to-side anastomosis using running sutures

Click here to view
Figure 12: Interrupted suture technique for end-to-side anastomosis

Click here to view


The type of anastomosis (EEA vs. ESA) in the head and neck has been controversial.[9],[10],[11] Advantages of EEA are that laminar flow is maintained and the incidence of thrombus formation is reduced. However, more recent reports suggest that ESA does not increase the incidence of anastomotic failure and that blood flow rate is not significantly altered.[10],[12],[13],[14] Ueda has demonstrated that the incidence of thrombosis was 1.8% (15 of 835) after EEA to various veins and 2.7% (3 of 113) after ESA to the IJ vein.[10] There was no significant difference in the two. Another study retrospectively compared EEA and ESA from over 2000 microvascular anastomoses and found no significant difference in the failure rate of arterial or venous anastomoses.[15] Advocates of the ESA technique cite additional benefits.[9],[12],[16] These include multiple anastomoses to a single vessel, overcoming discrepancies in vessel size, avoidance of vessel retraction, etc.

End-to-side branch anastomosis

The technique of end-to-side branch anastomosis is a modification of the ESA, in which an arterial branch or venous tributary, located at the selected anastomotic site, is used as a recipient site vessel.[17] The donor vessel is anastomosed to the side branch using a conventional EEA technique.

This method of anastomosis, if available, may be preferable to an ESA technique, especially if clinical conditions are suboptimal.

End-in-end anastomosis

The end-in-end intussusception method, originally known as the sleeve anastomosis, was introduced into microsurgery by Lauritzen. This technique requires the upstream vessel to be placed inside the downstream vessel to make an overlap, or sleeve, in order to prevent leakage [Figure 13]. This technique is superior to end-to-end sutured anastomosis because it is faster, there is less intimal dissection, no aneurysms at the anastomotic site, and resistance to irradiation is greater.[17],[18]
Figure 13: End-in-end or sleeve anastomotic technique

Click here to view



  Fixation Methods in Microvascular Anastomosis Top


Various methods of anastomotic fixation have been investigated.[17] The goal is to find simpler and faster techniques without decreasing the patency rates. Fixation methods which are used include sutured anastomosis, laser techniques, electrocoaptation, mechanical devices, adhesive anastomoses.

Suturing is the most versatile method of microvascular anastomoses and can be used in any clinical situation.

Laser-assisted microvascular anastomoses has been evaluated in various experimental models and in a few clinical series.[19] The patency rates obtained are comparable with those obtained with conventional manual sutures with the advantage of shorter operative times, limited endothelial trauma with small thrombogenic risk, and no suture material to trigger a foreign-body reaction.[20],[21],[22]

Electrocoaptive microvascular anastomoses involves producing an adherent and localized coagulam by the passage of high frequency electric current through the adjacent tissues.[17] However the technique has not been widely used.

Clinical series of vessels anastomosed with mechanical coupling devices [Figure 14] have shown equal or greater patency rates and faster anastomosis of either normal or irradiated vessels.[19] They are commonly accepted in venous anastomoses, however, their use in arterial anastomoses remains limited. Yap et al.[23] reported no statistically significant difference between the two techniques. Chernichenko et al.[24] reported a failure rate of 1% in 134 patients with venous ESA with a coupling device. Delacure et al.[11] reported 100% success rate with the use of microvascular anastomotic coupling device (MACD) in venous ESA. Reddy et al.[25] successfully reviewed the use of nonpenetrating vascular closure staple (VCS Anastoclip) in microvascular anastomosis over a 13 year period in 819 free flap reconstructions and reported that the VCS device is as effective as sutured anastomoses in free tissue transfer surgery. A number of different types of adhesives for microvascular anastomoses have been investigated such as cyanoacrylic adhesives, polyurethane resin, adhesive tapes, and fibrinogen adhesives.[17],[26],[27] Pearl et al.[28] showed, in an experimental model, that microvascular anastomosis with a biologic sealant adhesive significantly reduces hemorrhage and reduces operative time, while allowing a flap survival comparable to that obtained with standard techniques. These adhesives can be used as alternatives to conventional suturing, however, further studies need to be conducted regarding their efficacy.
Figure 14: Anastomotic coupling device

Click here to view



  Microvascular Anastomoses in Previously Irradiated Vessels Top


Radiotherapy is known to impair wound healing by decreasing the number of blood vessels in tissue by progressive thrombosis, resulting in tissue ischemia by decreasing fibroblast proliferation and production of collagen and by destroying epithelial cells.[19] Most clinical studies have demonstrated that prior radiotherapy in the head and neck does not adversely affect flap survival and anastomotic patency.[29],[30] However, in some studies perivascular fibrosis and endothelial damage have been described.[31],[32] More recent studies have further elucidated the anatomic and physiologic changes associated with the effect of radiation on arteries and veins.[33] Herle et al.,[34] in their study, reported that preoperative radiation in excess of 60 Gy is associated with a statistically significant increased risk of flap complications, failure, and fistula.

Guelincks [35] has proposed the following guidelines for anastomosis of irradiated recipient vessels:

  • Limit dissection of recipient vessels to reduce manipulation and injury
  • Restrict electrocoagulation of arterial side branches
  • Use small-gauge needles and suture materials
  • Pass the microneedle from inside to outside to minimize intramural dissection and injury
  • Shorten the period of vessel cross-clamping to minimize stasis and microthrombi
  • Flush vessels with a heparinized solution during the anastomosis and before restoring blood flow.



  Microvascular Grafts and Prosthesis Top


Sometimes, it is not possible to repair a vessel by anastomosing the cut ends, such as in cases of traumatic loss or when additional vessel resection is needed. In such cases, grafts of autogenous veins are the most common substitute circulatory conduits.[19] The use of interposition vein grafts is an effective means of increasing the length of the vascular pedicle.[36],[37],[38],[39] Early studies evaluating the use of interposition vein grafts for microvascular reconstruction in the head and neck demonstrated a 30% failure rate compared with a 5% failure rate when no interposition vein grafts were used.[40] Recent studies have demonstrated that there is no difference in survival after free tissue transfer with and without the use of vein grafts.[37] In a study of 340 patients, Germann and Steinau demonstrated that the incidence of flap survival with vein grafts (55 patients) and without vein grafts (275 patients) were equal (96.2 and 96.7%, respectively). However, the percentage of flaps requiring revision of the anastomosis was greater for free flaps with vein grafts than without (14.8 and 8.7%, respectively).

Despite the success with autogenous vein grafts, experimental investigation of synthetic materials to replace small vessels continues.[19] The most common materials tested for this purpose are fibrous polyurethane (PU) and microporous or expanded polytetrafluoroethylene (PTFE). However, more studies need to be conducted regarding their efficacy.


  Microvascular Free Flaps Commonly Used in Maxillofacial Reconstruction Top


Radial forearm flap

The radial forearm fasciocutaneous flap (RFFF) which is the “workhorse” microvascular flap for the head and neck was first described by Yang,[41] in 1981. It provides a large, thin, pliable, predominantly hairless flap for intraoral and oropharyngeal lining.[1] It is commonly used for the tongue, floor of mouth, lip and hard palate reconstruction.[42] The entire skin in the volar aspect of the forearm can be harvested with the long pedicle, permitting anastomosis to the contralateral neck also. Microvascular anastomosis of large-caliber radial vessels ensures successful transfer of this flap.

Other advantages of this flap are the presence of large diameter superficial veins (cephalic or basilic) and deep venous system (the venae comitantes). Studies have shown that the smaller venae comitantes give reliable venous outflow, however, due to their smaller caliber, microvascular anastomosis is difficult compared to the cephalic vein. Functional recovery from the forearm defect is quite acceptable and there is minimal residual discomfort.

Fibula osseocutaneous flap

This flap was first described by Taylor in 1975 for lower extremity reconstruction, but it was Hidalgo,[43] in 1989, who introduced the fibula osseocutaneous flap (FOCF) for mandibular reconstruction. This flap is widely used for oromandibular reconstruction following oncological resections or trauma, and is an emerging choice after maxillary section.[1]

The fibula provides the longest segment of bone with 20–30 cm available for harvest.[44] In addition, the segmental blood supply of the bone permits multiple osteotomy. The bone is also of adequate width and height to allow placement of osseointegrated dental implants. Donor site morbidity with this graft is minimal, unless the distal osteotomy site is within 6 cm of the ankle. In addition, the location of the graft allows simultaneous harvest by a second team at the time of tumor resection.

Experiences in pediatric patients have been encouraging because it is one of the safest flaps to harvest in pediatric population with iliac crest and scapula causing growth disorders later in life.[45]

One of the major disadvantages of fibular free flap is the limited availability of the skin and soft tissue necessary for reconstruction of mucosal defects.[1] Donor site morbidity is a problem, mainly involving split-thickness skin grafts or primary closure. Another disadvantage of the fibula flap is the low quality of vessels seen in patients with peripheral vascular disease such as arteriosclerosis.[42] In these cases, the scapula may be a better option.

Iliac crest osteocutaneous flap

The iliac crest osteocutaneous flap (ICOF), which is based on the deep circumflex iliac artery and vein (DCIA and DCIV), was described by Taylor's dye injection studies in 1979.[4] Along with the skin and bone, the flap can include the internal abdominal oblique muscle based on the ascending branch of the DCIA. This allows the flexibility of a thin, mobile soft tissue component along with the relatively immobile cutaneous and osseous constituents of the flap.

The greatest advantage of DCIA-based flaps is the quality and quantity of the bone that can be harvested. The ilium is well-suited for reconstruction of nearly all but the largest mandibular defects. It is best suited for defects (up to 16 cm) of the mandibular ramus and body because of its natural curvature and the ease of designing patterns to reconstruct the mandibular angle without osteotomies.

The disadvantages of this flap include unpredictable and inflexible skin paddle, lesser length of bone stock, and the risk of postoperative donor site pain and hernia.[46] Iliac crest is now only a second-line option and has fallen behind the fibula as the donor site of choice for mandibular reconstruction.

Scapula flap

The scapular flap provides a small segment of the scapula, along with a large portion of the skin and soft tissues.[1] This flap is useful for restoring the bony and soft tissue contours of the face and achieving rigid support for the velum, oronasal separation, support for the orbit, and obliteration of the maxillary sinus. The flap is based over the circumflex scapular artery and vein. It has a long vascular pedicle of 6–14 cm, and arterial diameter is 1.5–4.5 mm. Elevation of the flap is rapid and easy, and thickness is variable (1.5–3 cm).

Drawbacks of this flap include the limited amount of bone and soft tissue available. In many centers, the fibula has replaced both the scapula and iliac crest as the flap of choice for mandibular reconstruction.[47] In large volume centers, it is not favored much because the two-team approach cannot be used and the repositioning of the patient for flap harvest is time consuming.[1]

Anterolateral thigh flap

The anterolateral thigh flap (ALTF) is based on the cutaneous perforators of the descending branch of the lateral circumflex femoral artery, a branch of the profunda femoris.[4] No special preoperative evaluation is needed prior to flap harvesting. The maximum area that this flap can support is up to 800 cm 2, consisting of skin from the level of the greater trochanter of the femur to a line 3 cm above the patella.

One great advantage of this flap is the possibility of harvesting a very thin flap (as little as 5 mm of thickness) while maintaining the suprafascial vascular plexus based on the perforating vessels. Other advantages include low donor site morbidity, simultaneous harvest, large volume of skin and soft tissue available, a long pedicle, acceptability of site for the scar, and ability to harvest as subcutaneous, fasciocutaneous, musculocutaneous, or adipofacial flap, thus giving multiple applications for this flap.[42] The variation in vascular anatomy and the inconsistent location of cutaneous perforators has impeded this flap's overall acceptance for head and neck reconstruction.


  Conclusion Top


The use of microvascular techniques for free tissue transfer has revolutionized reconstruction and expanded the range of options for reconstructing large anatomic defects in patients. Microsurgery is complex and technically demanding, however, with careful preparation and proper execution, it can be beneficial to the patient and rewarding to the surgeon. There appears to be an increasing number of surgeons actively involved in microvascular reconstruction and, essentially, the technique of microvascular surgery has been perfected over the past few years. It results in excellent postoperative cosmetic and functional results and the success of microvascular anastomosis is >95%.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Rinaldo A, Shaha AR, Wei WI, Silver CE, Ferlito A. Microvascular free flaps: A major advance in head and neck reconstruction. Acta Otolaryngol 2002;122:779-84.  Back to cited text no. 1
    
2.
Yap LH, Butler CE. Principles of Microsurgery. In: Thorne CH, editor. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2007. p. 66-72.  Back to cited text no. 2
    
3.
Tyagi S, Kumar S. Microsurgery: An important tool for reconstructive surgery-A Review. Int J Pharma Bio Sci 2010;1:1.  Back to cited text no. 3
    
4.
Kim DD, Ghali GE. Microvascular free tissue reconstruction of the oral cavity. SROMS 2004;12:1-36.  Back to cited text no. 4
    
5.
Kruse AL, Luebbers HT, Grätz KW, Obwegeser JA. Factors influencing survival of free-flap in reconstruction for cancer of the head and neck: A literature review. Microsurgery 2010;30:242-8.  Back to cited text no. 5
    
6.
Chalian AA, Anderson TD, Weinstein GS, Weber RS. Internal jugular vein versus external jugular vein anastamosis: Implications for successful free tissue transfer. Head Neck 2001;23:475-8.  Back to cited text no. 6
    
7.
Urken ML. Recipient vessel selection in free tissue transfer to the head and neck. In: Urkin ML, Cheney ML, Sulliven MJ, Biller HF, editors. Atlas of Regional and Free Flaps for Head and Neck Reconstruction. New York: Raven Press; 1995, p. 331-7.  Back to cited text no. 7
    
8.
Carrel A. The operative technique of vascular anastomosis and transplantation of organs. Lyon Méd 1902;98:859.  Back to cited text no. 8
    
9.
Yamamoto Y, Nohira K, Kuwahara H, Sekido M, Furukawa H, Sugihara T. Superiority of end-to-side anastomosis with the internal jugular vein: The experience of 80 cases in head and neck microsurgical reconstruction. Br J Plast Surg 1999;52:88-91.  Back to cited text no. 9
    
10.
Ueda K, Harii K, Nakatsuka T, Asato H, Yamada A. Comparison of end-to-end and end-to-side venous anastomosis in free-tissue transfer following resection of head and neck tumors. Microsurgery 1996;17:146-9.  Back to cited text no. 10
    
11.
DeLacure M, Kuriakose M, Spies AL. Clinical experience in end-to-side venous anastomoses with a microvascular anastomotic coupling device in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 1999;125:869-72.  Back to cited text no. 11
    
12.
Albertengo JB, Rodriguez A, Buncke HJ, Hall EJ. A comparative study of flap survival rates in end-to-end and end-to-side microvascular anastomosis. Plast Reconstr Surg 1981;67:194-9.  Back to cited text no. 12
    
13.
Oğuz Yenidünya M, Yenidünya S, Suse T, Tosa Y, Hosaka Y, Morohoshi T. Different types of arteriovenous anastomoses between femoral artery and vein distal to the island groin flap. J Reconstr Microsurg 2002;18:301-7.  Back to cited text no. 13
    
14.
Fillinger MF, Kerns DB, Bruch D, Reinitz ER, Schwartz RA. Does the end-to-end venous anastomosis offer a functional advantage over the end-to-side venous anastomosis in high-output arteriovenous grafts. J Vasc Surg 1990;12:676-88.  Back to cited text no. 14
    
15.
Samaha FJ, Oliva A, Buncke GM, Buncke HJ, Siko PP. A clinical study of end-to-end versus end-to-side techniques for microvascular anastomosis. Plast Reconstr Surg 1997;99:1109-11.  Back to cited text no. 15
    
16.
Bas L, May JW Jr, Handren J, Fallon J. End-to-end versus end-to-side microvascular anastomosis patency in experimental venous repairs. Plast Reconstr Surg 1986;77:442-50.  Back to cited text no. 16
    
17.
Malizos KN. Microvascular Surgical Techniques. In : Malizos KN, editor. Reconstructive Microsurgery. Spi Ed. Georgetown, Texas: Landes Bioscience; 2003. p. 1-7.  Back to cited text no. 17
    
18.
Duminy FJ. A new microvascular “sleeve” anastomosis. J Surg Res 1989;46:189-94.  Back to cited text no. 18
    
19.
Griffin JR, Thornton JF. Microsurgery: Free tissue transfer and replantation. Selected Readings Plast Surg 2000;9:19-34.  Back to cited text no. 19
    
20.
Samonte BR, Fried MP. Laser-assisted microvascular anastomosis using CO2 and KTP/532 lasers. Lasers Surg Med 1991;11:511-6.  Back to cited text no. 20
    
21.
Flemming AF, Colles MJ, Guillianotti R, Brough MD, Bown SG. Laser assisted microvascular anastomosis of arteries and veins: Laser tissue welding. Br J Plast Surg 1988;41:378-88.  Back to cited text no. 21
    
22.
Reali UM, Gelli R, Giannotti V, Gori F, Pratesi R, Pini R. Experimental diode laser-assisted microvascular anastomosis. J Reconstr Microsurg. 1993;9:203-10.  Back to cited text no. 22
    
23.
Yap LH, Constantinides J, Butler CE. Venous thrombosis in coupled versus sutured microvascular anastomoses. Ann Plast Surg 2006;57:666-9.  Back to cited text no. 23
    
24.
Chernichenko N, Ross DA, Shin J, Sasaki CT, Ariyan S. End-to-side venous anastomosis with an anastomotic coupling device for microvascular free-tissue transfer in head and neck reconstruction. Laryngoscope 2008;118:2146-50.  Back to cited text no. 24
    
25.
Reddy C, Pennington D, Stern H. Microvascular anastomosis using the vascular closure device in free flap reconstructive surgery: A 13-year experience. J Plast Reconstr Aesthet Surg 2012;65:195-200.  Back to cited text no. 25
    
26.
Yamagata S, Handa H, Taki W, Yonekawa Y, Ikada Y, Iwata H. Experimental nonsuture microvascular anastomosis using a soluble PVA tube and plastic adhesive. J Microsurg 1979;1:208-15.  Back to cited text no. 26
    
27.
Kim BY, Choi BH, Huh JY, Lee SH, Zhu SJ, Cho BP. Microvascular anastomosis using cyanoacrylate adhesives. J Reconstr Microsurg 2004;20:317-21.  Back to cited text no. 27
    
28.
Pearl RM, Wustrack KO, Harbury C, Rubenstein E, Kaplan EN. Microvascular anastomosis using a blood product sealant-adhesive. Surg Gynecol Obstet 1977;144:227-31.  Back to cited text no. 28
    
29.
Bengtson BP, Schusterman MA, Baldwin BJ, Miller MJ, Reece GP, Kroll SS, et al. The influence of prior radiotherapy on the development of postoperative complications and success of free tissue transfers in head and neck cancer reconstruction. Am J Surg 1993;166:326-30.  Back to cited text no. 29
    
30.
Mulholland S, Boyd JB, McCabe S, Gullane P, Rotstein L, Brown D, et al. Recipient vessels in head and neck microsurgery: Radiation effect and vessel access. Plast Reconstr Surg 1993;92:628-32.  Back to cited text no. 30
    
31.
Bernstein EF, Sullivan FJ, Mitchell JB, Salomon GD, Glatstein E. Biology of chronic radiation effect on tissues and wound healing. Clin Plast Surg 1993;20:435-53.  Back to cited text no. 31
    
32.
Schultze-Mosgau S, Grabenbauer GG, Radespiel-Troger M, Wiltfang J, Ries J, Neukam FW, et al. Vascularization in the transition area between free grafted soft tissues and pre-irradiated graft bed tissues following preoperative radiotherapy in the head and neck region. Head Neck 2002;24:42-51.  Back to cited text no. 32
    
33.
Nahabedian MY, Singh N, Deune EG, Silverman R, Tufaro AP. Recipient vessel analysis for microvascular reconstruction of the head and neck. Ann Plast Surg 2004;52:148-55.  Back to cited text no. 33
    
34.
Herle P, Shukla L, Morrison WA, Shayan R. Preoperative radiation and free flap outcomes for head and neck reconstruction: A systematic review and meta-analysis. ANZ J Surg 2015;85:121-7.  Back to cited text no. 34
    
35.
Guelinckx PJ, Boeckx WD, Fossion E, Gruwez JA. Scanning electron microscopy of irradiated recipient blood vessels in head and neck free flaps. Plast Reconstr Surg 1984;74:217-26.  Back to cited text no. 35
    
36.
Zhang F, Ho PR, Chin BT, Ozek C, Buncke HJ, Lineaweaver WC. Effect of vein grafting on the survival of microvascularly transplanted muscle. Microsurgery 1996;17:512-6.  Back to cited text no. 36
    
37.
Germann G, Steinau HU. The clinical reliability of vein grafts in free flap transfer. J Reconstr Microsurg 1996;12:11-7.  Back to cited text no. 37
    
38.
Harris JR, Seikaly H, Calhoun K, Daugherty E. Effect of diameter of microvascular interposition vein grafts on vessel patency and free flap survival in the rat model. J Otolaryngol 1999;28:152-7.  Back to cited text no. 38
    
39.
Aitasalo K, Relander M, Virolainen E. The success rate of free tissue transfer after preoperative irradiation in head and neck reconstruction. Ann Chir Gynaecol 1997;86:311-7.  Back to cited text no. 39
    
40.
Miller MJ, Schusterman MA, Reece GP, Kroll SS. Interposition vein grafting in head and neck reconstructive microsurgery. J Reconstr Microsurg 1993;9:245-52.  Back to cited text no. 40
    
41.
Yang G, Chen B, Gao Y. Forearm free skin flap transplantation. Nat Med J China 1981;61:139-41.  Back to cited text no. 41
    
42.
George RK, Krishnamurthy A. Microsurgical free flaps: Controversies in maxillofacial reconstruction. Ann Maxillofac Surg 2013;3:72-9.  Back to cited text no. 42
[PUBMED]  Medknow Journal  
43.
Hidalgo DA. Fibula free flap: A new method of mandible reconstruction. Plast Reconstr Surg 1989;84:71-9.  Back to cited text no. 43
    
44.
Rahman QB, Rahman M, Mamun S, Iqbal M, Das BK. Reconstruction of mandibular defect by free re-vascularized fibula graft: A case report. BSMMUJ 2008;1:35-8.  Back to cited text no. 44
    
45.
Ferri J, Piot B, Ruhin B, Mercier J. Advantages and limitations of the fibula free flap in mandibular reconstruction J Oral Maxillofac Surg 1997;55:440-8.  Back to cited text no. 45
    
46.
Kim EK, Evangelista M, Evans GR. Use of free tissue transfers in head and neck reconstruction. J Craniofac Surg 2008;19:1577-82.  Back to cited text no. 46
    
47.
Wei FC, Demirkan F, Chen HC, Chen IH. Double free flaps in reconstruction of extensive composite mandibular defects in head and neck cancer. Plast Reconstr Surg 1999;103:39-47.  Back to cited text no. 47
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]


This article has been cited by
1 Biomechanical comparison of microvascular anastomoses prepared by various suturing techniques
Balazs Szabo,Laszlo Fazekas,Souleiman Ghanem,Zoltan A. Godo,Jozsef Madar,Aniko Apro,Norbert Nemeth
Injury. 2020;
[Pubmed] | [DOI]
2 Posterior external jugular vein: a useful alternative recipient vessel in head and neck free flap reconstructions
Ryogo Kuba,Yusuke Shimizu,Reina Kitabata,Shun Yamazaki
European Journal of Plastic Surgery. 2020;
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Selection of Rec...
Technique of Mic...
Types of Anastomosis
Fixation Methods...
Microvascular An...
Microvascular Gr...
Microvascular Fr...
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed4198    
    Printed81    
    Emailed0    
    PDF Downloaded569    
    Comments [Add]    
    Cited by others 2    

Recommend this journal